The lowest rung in mental health care.

anxiety

“Nathan” was a broad shouldered kid of 16 when I first worked with him. It was good to get him out of the unit and active, it took the edge off him. He was competitive, but a good sport, and enjoyed playing basketball and football. He was well liked by his peers. Nathan was also good looking, but didn’t seem to realize it.

This last was good. There were girls who were interested. But girls in treatment, well, the kind that attempted to get his attention, are sexualized beyond their years and prone to unending drama. His apparent cluelessness saved him a lot of grief.

Nathan was fairly high functioning, as compared to most of our kids. He focused on treatment and did not get sidelined by peer negativity. The obvious reasons for why he was here were persistent anxiousness and impulsivity that led to outbursts. These outbursts were usually limited to verbal disrespect and broken furniture, though he had been suspended from school a couple times.

The thing is, though, we really didn’t see the verbal defiance. We saw a kid who responded well to structure and male authority figures. His father wasn’t in the picture. Nathan liked groups, participated well and really appreciated the white board. In residential treatment the white board has the day’s schedule, activities and appointments and is used to keep track of the location of clients and staff.

The combination of groups and the visual organization of the white board can have a grounding effect on kids who lag behind their peers in areas of executive functioning or internal structure. This was really the case with Nathan. In fact, Nathan identified this as something that would help in the home. His Mom was willing to try this and bought a white board for when he arrived back home.

A month after discharge we got a call from Nathan. He was upbeat and positive and reported he was doing well. They had hung the white board in the kitchen and were reviewing the day’s schedule each morning going over what he was responsible for, such as starting dinner or meeting younger siblings at school and walking them home. Mom said his school attendance was up and their interactions were much better.

So, when Nathan returned to treatment about six months later it was a little surprising and discouraging to find out that while the white board had gotten broken, it then wasn’t replaced. Nathan was back, in part, due to the return of his old troublesome behaviors; getting escalated easily, not contributing in the home and school avoidance.

The underlying problem was his anxiety for the unknown and a lack of structure. Both of those had been addressed by the white board. It wasn’t just the existence of the white board, but the family taking the time to utilize it and review what makes it on to the board. This external structure was a family routine that needed to be maintained. But the white board wasn’t replaced and the new, successful habit fell to the wayside.

Something simple can make a difference

This illustrates the gap between what is identified and works in treatment and yet is not maintained in the home. It also is an example of a time where the parent has to be willing to step up and be an adult and change and lead by maintaining the tool or modality that is improving interactions.

Resistance from parents to Collaborative Problem Solving is often the notion that they have to accept disrespect or non-compliance. This isn’t the case. But, what usually is the case is that parents need to modify their behavior as well.

The parent of a child with Aspergers might have to greatly modify their tone such as eliminating sarcasm. A child who struggles with transitions might need more proactive discussions offering reminders and reassurances of what’s expected or on the schedule. And if a kid breaks the white board in a moment of frustration, when otherwise the family has been running more smoothly than in the recent past, you prioritize replacing it without attaching a consequence or trying to prove a point by holding it over his head.

Changing habits and patterns in a family unit is hard work, takes time, and all parties need to be amenable to feedback and be willing to change. Not just the kid. Because if the kid is doing the work alone he won’t succeed and the family unit will continue to operate in crisis mode.